Have you noticed that the majority of the drug commercials on TV spend 15-20% of the commercial telling you why you should use their drug, and the rest of the time warning you about all the potential side effects? It seem like the benefit list is getting shorter and the negative list is getting longer.

Take your smartphone stopwatch app or just watch a ticking second-hand and notice how many seconds of a drug commercial are spent on the positive effects list vs. the potential side effects list. I wonder who watches these commercials and hears, “hey there is a drug that can help your condition.” They then listen to the list of positive effects for 15 seconds, followed by 45 seconds of side effects and then rush to their doctor asking for that medication.

I have also noticed that frequently one of the items on the “side effects” list mentions SUICIDE. It seems that now the majority of the drug commercials make mention of suicidal tendencies as a possible “side effect’.

How common is suicide in America you ask? Some sources list suicide as the 8th leading cause of death; others list it as the 10th. These numbers are much higher than I would have guessed. As a matter of fact, more people die from suicide than die in automobile accidents. I could not believe what I read. I stopped to think about how many people I personally knew who had died in a car accident and how many suicides I was aware of. The numbers were close.

I have mentioned these numbers to every law enforcement patient I have. Each has replied something to the effect of: “That sounds about right.” I don’t know about you, but I am shocked by these numbers. Here are some other shocking suicide statistics:

- 8th (some report 10th) leading cause of death in the US

- 3rd cause of death among ages 15 to 24

- 38,000/year and this number is up from previous years

- 86/day in the USA

- 1500 attempted suicides per day

Here is another set of statistics that will give you something to think about. Thomas Magnuson, MD of the University Nebraska Medical Center found the following:

- 20% of suicide victims have seen their MD in the last 24 hours

- 40% of suicide victims have seen their MD in the last week

- 70% of suicide victims have seen their MD in the last 30 days

So, the vast majority of people who commit suicide are under very recent medical care. Many of these patients are taking multiple prescription drugs. Now remember all those commercials for popular medications warning of suicide ideation.

I thought, maybe these patients had gotten a horrible diagnosis and thus compelled to take their own lives. This does not appear to be the case. Instead, an altered mental state is the common suicide link. Depression is a factor with most suicides and attempted suicides. The state of the world and the US economy is not helping matters at all. But there have always been tough times throughout history. Why is suicide the 8th cause of death? Are there other causes that might be involved? Turns out, there are strong indications that diets lacking in certain minerals and other elements may be bigger contributors to depression, mental illness, and suicide than you might imagine. Serotonin is just one neurotransmitter that has been proven to be important factor in feelings of self-worth, well-being, and general happiness. Magnesium deficiency has also been indicated as an important player in a person’s mental status.

I invite you to read this research paper showing that supplementing a patient’s diet with something as simple as magnesium can may have a profound positive effects.

It states: “Antidepressant drugs are not always effective and some have been accused of causing an increased number of suicides particularly in young people.” The paper goes on to state that, “Case histories are presented showing rapid recovery (less than 7 days) from major depression using 125-300 mg of magnesium (as glycinate and taurinate) with each meal and at bedtime. Magnesium was found usually effective for treatment of depression in general use.” I have found this to true and have recommended magnesium supplementation when indicated with good successes, in 7 days or less. The paper goes on to state: “The possibility that magnesium deficiency is the cause of most major depression and related mental health problems including IQ loss and addiction is enormously important to public health and is recommended for immediate further study.” As with any supplementation, there needs to be some consideration as to what other medications the patient might be on and any conflicts or interactions and of course, consult your physician.

In comparison, one glowing research paper states that magnesium demonstrates a rapid response and profound positive effects vs. a paper from the Department of Psychiatry, Harvard Medical School titled Antidepressant drugs and the emergence of suicidal tendencies that states: “Although antidepressants diminish suicidal ideation in many recipients, about as many patients experience worsening suicidal ideation on active medication as they do on placebo.” And it closes by saying, “These observations suggest that antidepressants may redistribute suicide risk, attenuating risk in some patients who respond well, while possible enhancing risk in others who respond more poorly.” Not very promising news. Sounds like a coin flip to me. Some get better, some get worse, and some die by their own hand.

My advice is this: if a patient, friend, family member or co-worker gives any hint that they are in a crisis state, pay attention to what they are saying and/or doing. Don’t pass off the signs of crisis. If you are a doctor or nurse and see that a patient is on medication(s) that have suicide ideation as a possible side effect, bring up the topic and ask what their mental state is. If they are on antidepressants, ask them point blank, “Is it working for you?” Most of the time when it is working they will excitedly tell you YES, it is great.” Ask them, “You’re not worse on the medication, are you?” If so, help them right away. Consider suggesting exercise and other stress reducing actions and talk to them about giving magnesium a try. You may be a lifesaving hero for someone or at the very least, help them get out of a depressive state.

If you have a topic you would like us to research or if you would like to submit an article, please email skrueger@hna-net.com .

Like it or not, Obamacare (PPACA - The Patient Protection and Affordable Care Act), now the law of the land, is in the process of implementation as you read this. While its implementation is not complete until 2018, the majority of the provisions within the PPACA will be in place by 2014. As the US healthcare system pushes full speed ahead toward a national healthcare system, let’s take a look at who will benefit from this drastic change in American healthcare.

A cynic would say that the persons responsible for writing and passing Obamacare are the ones who will benefit the most. Politicians who want to make as many people as possible dependent on the government will certainly be re-elected by the American citizens who will remain or become dependent on the government subsidies. Very few voters will decide to cut their own benefits by electing fiscally-responsible legislatures.

Realistically, there is a population of Americans who will benefit from the PPACA. These are the unfortunate few who have enormous ongoing medical expenses due to genetic disabilities, permanent injuries, or chronic health problems. These individuals would typically see their healthcare premiums skyrocket, and only if they could obtain healthcare insurance in the first place. The PPACA prohibits insurance companies from denying coverage to persons with pre-existing conditions, from unduly raising premiums, or from cancelling policies on people who incur a major illness or injury. Whether the number of citizens who benefit from these changes in American healthcare insurance laws is large enough to justify completely overhauling the entire healthcare system remains a question to be answered, but at this stage of the game, it may be a moot point.

No matter which side of the healthcare debate you come down on, Obamacare will open a floodgate of potential healthcare abuse. While the primary focus is on possible patient abuse in National healthcare, the possibility of governmental abuse of the program is a much greater threat. Keep in mind that the person who was in charge of the IRS during its scandal has been reassigned to take charge of Obamacare. That should be frightening to every American. The government has decided that the best person to implement the PPACA is the person who allowed government employees to harass and deny Americans their fundamental rights to participate in the election process based on their political views.

One factor overlooked in the entire US healthcare debate is the fact that a consistent 60% or so of Americans do not favor the PPACA. These disgruntled Americans will be forced into a National healthcare system that they do not want to participate in, or get fined for not participating. A certain percentage of these normally law-abiding citizens, being forced into a system that they disapprove of, will become criminals out of spite. Wanting to make sure that they get their money’s worth of out of the system, they will engage in healthcare abuse without much regret. Their reasoning is that if they are being forced to pay for other Americans healthcare, either through fines or buying healthcare insurance which they do not want, they will be sure to get their share of healthcare and then some, which they have already paid for anyway.

With all the potential for patient abuse in National healthcare, it becomes more incumbent on each and every healthcare practitioner to be especially alert to the possibilities of healthcare abuse. By educating patients about the need to be responsible for their own health in order to minimize the amount of care that they require, you can do your part to control healthcare costs. Helping your patients to be responsible, and not to over-utilize unnecessary healthcare will help both doctor and patient from becoming embroiled in a possible healthcare fraud scenario.

Like it or not, we are all in this together, so we might as well do what we can to make the system work, at least until we can elect sane people to address the issue properly.

Now that it appears that the Patient Protection and Affordable Care Act (PPACA) will move forward and become implemented gradually over the next few years; it is paramount that we look at the long term consequences of the act.

One of the major provisions of the PPACA is that insurance companies must provide free screenings and preventive testing to all of their policy holders. Now everyone knows that there is no free lunch, so these “free” items provided to the policy holder are charged to every policy holder through higher insurance premiums. It is the same ploy used by other retailers.

For example a tire store may offer “free” tire balancing but charge $5 more for the tire than another shop that charges $5 for tire balancing, but sells their tires for $5 less. The idea behind forcing insurance companies to provide “free” screenings for their policy holders is to condition consumers to expecting “free” services while “taxing” everyone to pay for these services; through higher insurance premiums for everyone, even those who have no need or desire for these services. For example, very few men will need free breast cancer screenings, but the premiums they pay will reflect the cost of the “free” screenings.

Even if we admit that early and preventive testing will detect some diseases early and allow early treatment for some health problems, that doesn’t necessarily mean that healthcare costs will be contained. If a doctor finds that a patient has an elevated cholesterol level because they were able to order a free test, that is a good thing for both the patient and the doctor. But does early detection of high cholesterol actually save the healthcare system money?

Suppose that the doctor then places the patient on a cholesterol lowering drug to control the cholesterol level earlier than they would have if they had not known that the patient had a high cholesterol level. This would increase the cost to the healthcare system because the patient would spend more money on the drug. Also keep in mind the huge number of lawsuits being filed against the manufacturers of the cholesterol lowering drugs Crestor, Lipitor, and others. Placing more people on these drugs for longer periods on time will not reduce the number of these lawsuits.

Alternatively, the healthcare provider counsels the patient, actually performing the duties of a doctor (teacher in Latin) and informs the patient how a proper diet and lifestyle will reduce cholesterol levels and promote a healthier life. This approach would do more to reduce the cholesterol levels in the patient and improve overall health, with NO additional costs to the healthcare system. I would argue that the patient should follow these lifestyle patterns whether they have high cholesterol or not. A healthy lifestyle will prevent high cholesterol levels in the first place, negating the need for testing, whether or not a healthcare policy provides for a “free” cholesterol screen.

A healthy lifestyle should be promoted by the entire healthcare industry, whether patients have high cholesterol or not. Most intelligent people change the oil in their car regularly to prevent engine damage, they don’t wait until the “check oil” light comes on, because by then it is often too late and the damage is done. The human body is similar in that tests do not appear positive until damage has been done. The smart thing to do is to actively engage in a healthy lifestyle that will prevent the need for healthcare intervention.

The assumption that early screenings and preventive testing will save money and lives is just not true. Burdening doctors and insurance companies with the mandate that they provide “free” testing will not in and of itself improve the healthcare system. At best it may prolong some lives. At worse it will increase overall healthcare costs by placing more people on medication longer, or reinforcing the concept that it is OK to eat unhealthily and not live a healthy lifestyle because a certain test was negative. In the long run people will have a false sense of good health because of a good test result, and actually become unhealthier due to poor lifestyle choices.

The point is that the only real solution to the healthcare crisis in America is personal responsibility of each patient and healthy lifestyle choices. The entire healthcare profession should emphasize this goal, despite which services are provided “free” to the patient. Only when the entire healthcare profession embraces the concept of prevention rather than crisis management, as we now practice, will the healthcare problems in America be resolved. This must start with each individual healthcare provider in each private office. It begins with you, doctor!

We really want to know your opinions on this subject so please take a minute to post your comment below. Doctors and healthcare providers are in a very unsure situation in todays healthcare system and we want to know how it is affecting you and your practice.

President Obama's re-election to the White House will likely accelerate plans to comply with the Patient Protection and Affordable Care Act (PPACA). Tuesday's win for Obama will likely unleash a “torrent of rules that have been withheld until after the election," states David Merrit, managing director of intelligence business firm, Leavitt Partners. For example, payers can expect to see regulations for federal exchanges, guaranteed issues, rating limitations and community ratings, maybe even by the end of this week, Merritt noted.

This long awaited information would be welcome news for health insurers. As claimed by Independence Blue Cross President and CEO Daniel Hilferty, one of the biggest barriers to getting ready to implement the reform plan has been "the need for clear guidance from the U.S. Department of Health & Human Services,"

The clarifications that have been long awaited from the government will mostly affect insurers. "We do believe there are some key issues that need to be addressed, including the premium tax, essential benefits and age-rating restrictions," according to America's Health Insurance Plans spokesperson Robert Zirkelbach. But healthcare providers will also benefit from any clarifications as to which screenings and preventive procedures will be required to be provided to policy holders free of charge.

To fully implement reform provisions, health insurers must collaborate with state policymakers, since many of the provisions, such as Medicaid expansion and insurance exchanges, will be executed at the state level. With that in mind, Independence Blue Cross says it will keep working with policymakers to find bipartisan solutions to improve care and make it more affordable, according to Hilferty. That work might be easier said than done.

This past election, Republicans garnered 30 governorships, forcing a number of red state governors to implement a law they most likely oppose. Many of these same states have passed, or are currently debating whether or not they will accept the additional funding for expanding their state run Medicaid programs or reject the intrusion by the Federal government into state affairs.

Clarification from Health and Human Services (HHS) regarding the implementation of Accountable Care Organizations (ACOs) and Medical Homes will enable healthcare providers with better information as to which, if any, group they want to join. Compliance with all of the regulations that will be forthcoming over the next few months will clarify the entire healthcare picture.

One possible sticking point to the full implementation of the PPACA is that the Republicans still control the House, where all appropriation bills must be initiated by law. Despite the rhetoric from the proponents of the PPACA that the healthcare reform law would save billions in spending over the next ten years, Congress must appropriate billions of dollars to implement the PPACA. The Republicans, citing the continuing disapproval rating of around 60% for the PPACA may decide to withhold funding for the bill, which would delay its enactment, at least until the Supreme Court weighs in on the matter again.

To get to the original point of this article, to the private or small group healthcare provider, will the results of the election change much of the day to day activities in the office? Probably not much will change. The healthcare provider should still focus on providing quality healthcare for every patient who walks through their door. The practice will continue to run as a small business with one eye on the bottom line, and the other on providing quality service so that the business can grow through referrals and repeat business. Bedside manner will continue to be an important ingredient to a successful practice, as will clinical expertise.

Any business which provides quality service at a fair price will continue to succeed, no matter what obstacles are placed in the way by the government. The entrepreneurial spirit which has made America great will find a way to allow individual practices to thrive and continue to provide Americans with great healthcare.

Please let us know your opinion in the comment box below. We would love to hear what you think and what challenges you are facing during this change in our healthcare system.

As the entire healthcare industry is undergoing major reforms, maybe it is time that we look at updating one of the foundations of healthcare. The Hippocratic Oath has been is existence for centuries as an ideal on which a physician’s ethics has been based.

Even though everyone has heard of the Hippocratic Oath, there are very few physicians, let alone lay people, who have actually read it or know what it contains. For instance, the Hippocratic Oath doesn’t actually contain its most quoted part: “first do no harm.”

There have been several articles recently suggesting that as a part of the Hippocratic Oath we should add language to include: “do no financial harm.” A variety of factors have come together in order for us to get to this point. But one large factor is that doctors claim that they don’t know how much the tests that they order cost. I find it hard to believe that doctors don’t know how much tests or procedures cost, but if in fact this is true, many doctors are in for a rude awakening when we return to the era of managed care, this time under the guise of Accountable Care Organizations and Medical Homes. Interestingly enough, many of these same doctors know that Medicaid doesn’t reimburse well enough to cover the costs of many procedures so they refuse to accept new Medicaid patients or are threatening to quit practicing medicine altogether.

A recent study in Archives of Surgery claims that “Simply reminding doctors how much money blood tests costs could cut back unnecessary medical spending and save hospitals thousands of dollars.” By sending weekly reminders to the doctors working within the hospital, the hospital saved over 27% on their phlebotomy costs during the study period.

There are other areas throughout the healthcare process where costs can definitely be contained through judicious choices by the attending doctor to reduce costs. One of the most significant ways is fully explain all of the options available to the patient so that they can make a true “informed consent” decision. This means informing the patient about ALL of their options, including alternative health care options for many conditions. There have been many studies over the years that have compared the results of alternative healthcare treatment to medical treatment for numerous conditions. These studies have concluded that overwhelmingly, the alternative treatment is more beneficial and at a lower cost for many typical, non-life threatening conditions.

The most noticeable examples are the studies comparing chiropractic treatment to medical treatment for low back conditions. If primary care physicians would simply refer all patients with low back conditions to chiropractors as the first option for treatment of low back pain, the savings to the entire healthcare system would amount to billions of dollars. Another example of where treatment dollars can be saved is by not ordering routine MRIs for patients with low back pain, as several studies dating back as far as the 1990’s have demonstrated no correlation between pain and positive MRI findings in low back conditions.

Giving patients every available option, along with probable outcomes and possible side effects, will allow patients the best opportunity to make the best decision regarding their treatment. Costs may also be required in future “informed consent” releases indicating that the physician has duly fulfilled their obligation

The doctor of the future will need to become aware of the cost of certain treatments or procedures and take this into account when treating patients. This will require doctors becoming more educated on alternative healthcare and the costs of test and procedures. If the medical establishment isn’t leading the effort to reduce costs for healthcare, there will be plenty of other entities that will. By demonstrating an effort to control costs from the healthcare provider’s side, a more favorable outcome may be obtained. Leaving outside entities to determine how much and for which procedures the medical community will be reimbursed will not be in the best interests of either patients or doctors. The entire healthcare profession needs to be pro-active and lead in true healthcare reform.

The answer is “Yes”, depending on how the question is worded, or who you are asking. There are so many variables concerning the Patient Protection and Affordable Care Act (PPACA or ACA) that no one really knows the answer to this question. But, you can provide your own answer to the question, based on the following assumptions:

An estimated 10-15 million new Americans will qualify for Medicaid due to the passage of the ACA

The ACA will cut the Federal deficit by $500 billion

Who do you think will have to pickup the tab? Now, personally, I don’t believe any of the figures that are bandied about by either side when it comes to the actual dollar amount that the ACA will cost or save to implement. The truth is that no one knows how it will shake out. But, just relying on past history, the government projections have consistently vastly underestimated the cost of any social program.

The gist of the Medicaid reform enacted through the ACA is that the Federal government will pay the states 100% of the additional costs associated with the expanded eligibility for people to qualify for Medicaid when the new program begins January 1st, 2014, then pay 95% in 2015, and 90% in 2016 and thereafter. The issue isn’t just a monetary one, for many states, especially those with majority Republican legislators; it is an issue of state’s rights.

The concern that the Republican controlled state legislations have is that they would be forfeiting some of their constitutionally guaranteed freedoms by being coerced into expanding Medicaid as mandated by the ACA. The Supreme Court agreed, ruling that the Federal government can offer incentives to states in order to entice them to comply with the ACA, but the Federal government cannot coerce states into compliance with the ACA.

This ruling by the Supreme Court on the Constitutionality of coercing the states to accept the Medicaid expansion opens a whole new can of worms. There will be numerous lawsuits arising at the state level citing this precedent in a number of Federal programs which the states are now coerced into compliance.

The proponents of the ACA use all sorts of word games in trying to convince the public that expanding the Medicaid program will save money while it benefits those who enroll in the program. One recent article claimed:

“Despite critics of the Medicaid reform ruling, Medicaid expansion will cover 17 million low-income people at only "modest" costs to states, according to yesterday's report from the Center on Budget and Policy Priorities.”

And

“Regardless of claims that states will eat the costs of expanding Medicaid, the report noted reform actually will reduce state and local government costs for uncompensatedcare.”

“Modest” is a vague term and “uncompensated care” is a minor component of the Medicaid expenditure. A second recent report claimed that the mortality rate will decrease by about 6% with the expansion of Medicaid. I’m fairly certain that the mortality rate will be 100% in the long run.

Another blogger recently slipped and claimed that the Supreme Court ruling allowing states to opt out of the ACA is only a minor setback on the road to a single payer system in America. That is also the fear of the states hesitant to expand Medicaid eligibility. As more and more Americans become dependant on the government for their healthcare, it will become easier to convince them that everyone should be covered by the government for their healthcare.

The two opposing views are clearly defined by the following two statements:

Senate Finance Committee Chairman Max Baucus, a Montana Democrat: "Repealing the law would only set our health care system back … Now it's time to stop the political gaming, implement the law and help as many Americans as possible get access to high-quality health care."

But Sen. Orrin Hatch (R-Utah), Baucus's counterpart on the Finance Committee: "CBO exposed the President's partisan health law for what it is: a massive expansion of government paid for with over a trillion dollars in tax increases. Higher health care costs, more government spending, higher taxes while slashing seniors' access to Medicare is why the American people continue to oppose this law. It's bad to its core and must be repealed."

For Medicaid patients this whole debate may be a moot point. In recent surveys, roughly 50% of responding doctors who accept Medicaid were not excepting new Medicaid cases. Another survey claimed that over 33% of current doctors plan to retire or change careers rather than comply with the increased cost and involvement with the increased paperwork to comply with the mandates outlined in the ACA.

It is not clear if the expansion of the Medicaid law will cost states or not. What is clear is that this is a step on the road to socialized medicine, which even the proponents are letting slip.

The Patient Protection and Affordable Care Act of 2011 (PPACA or ACA) will have a dramatic affect on every insurance company in America. How these changes will ultimately affect Americans and healthcare providers will depend on how insurance companies adapt to meet all the requirements of the ACA while they attempt to remain profitable.

Let’s be perfectly clear on one item: The purpose of the ACA is to force insurance companies out of business, so that the only option available for Americans is to depend on the government to provide healthcare insurance. Get ready for Medicare/Medicaid type coverage for patients and reimbursement levels for healthcare providers.

At first glance you would think that insurance companies would benefit greatly from an additional 35+ million newly insured Americans who are forced to buy health insurance. It is this fact that most upsets liberals about the ACA. They think that forcing Americans to buy healthcare insurance will only add to the coffers of insurance companies. It will be true that insurance companies will collect billions of dollars in additional premiums due to more Americans acquiring health insurance. However, the requirement that every heath insurance policy provide for no-out-of-pocket testing and screening, no annual or lifetime limits on benefits, no cancellation provisions, no eligibility requirements, and other mandates will more than offset any increase in revenue.

Insurance companies are required outlays for treatment equal to or greater than 85% of the premiums collected in healthcare benefits. A quick internet search did not result in any information on how efficient Medicare/Medicaid programs are, but I’m guessing that they do not meet this requirement. Another provision within the ACA requires that insurance companies must ask the Federal government for permission to raise insurance premiums and to justify the reason for any rate increase request. What are the chances that the Federal government will approve rate increases when they are requested?

The problem with the one size fits all philosophy of the insurance mandates within the ACA and the premise that more screenings and early testing is the fallacy that early detection will reduce medical costs. Just the opposite is true. If you detect a heart condition in a 20 year old vs. a 50 year old, it just means that the 20 year old will be medication for an additional 30 years, paid for by the insurance company. The idea that early detection will prevent more costly treatment is also false. Medical treatment consists of medication or surgery, neither of which prevents any disease. The only way to prevent disease is through lifestyle, and if early detection forces a patient to change their lifestyle, I would argue that they should have been living a healthy lifestyle in the first place, so there would be no need for any testing. The results of a test will rarely cause anyone to change their lifestyle, especially if they believe treatment is free.

A very interesting case study has recently presented itself in the State of Wisconsin. For years the state teacher’s association union officials have negotiated contracts with local school boards mandating that the healthcare insurance for the teacher union members be purchased through the Wisconsin Educational Association (WEA) trust. The WEA trust provided healthcare insurance coverage for the union members, and they were typically awarded the contract in a no bid process. As part of Governors Scott Walker’s reform plan the State employee unions could only negotiate wage contracts, not benefits. This freed up local school boards to seek healthcare insurance contracts in an open bidding process. Not surprisingly, most school boards were able to save enough on their healthcare insurance costs to avoid laying off teachers or cutting programs. In some districts the WEA trust agreed to lower their premiums to meet any outside competitor.This is just another example of the free market wringing out the excess in any industry by allowing competition. This works every time it is tried, no exceptions.

The state run insurance exchanges may be somewhat beneficial to consumers as they are supposed to allow individuals and companies to compare apples to apples when comparing insurance policies; and possibly lower insurance premiums as consumers become more educated.

A workable solution to the ever rising costs of healthcare insurance (as opposed to healthcare itself) is to open up competition among insurance companies, allowing them to sell policies across states. Allow policy holders to choose the benefits that they desire ala-carte, let them choose the deductable that best fits their individual situation, and limits on total benefits. We allow this type of competition in life insurance, auto insurance, and home insurance, so it appears that Americans are intelligent enough to buy, and pay for, these types of insurance; and no one is up in arms over the costs or availability of these types of insurance. Another solution is to expand Health Savings Accounts (HSA’s) which provide people with an incentive to live a healthy lifestyle since they get to keep any money in their account not spent on healthcare.

Time will tell if I’m right or not, but in my opinion, all the signs point this way.

Americans hate to be told what to do! How many times has a patient walked into your office and told you that they saw a commercial on TV and they want a specific drug? Or they self-diagnosed themselves on the internet and they just need a referral. Even owning your own practice you can’t get away from being told what to do. And we play nice until it is time to not play nice. After all, you are the one with the medical degree, if you could get a doctorate on Google for $19.95 every 19 year old in their parents basement would be treating cancer.

Now imagine that the government created the Kool-Aid Committee. And this committee’s only purpose was to make the American public drink one glass of grape Kool-Aid every day. Would you drink the Kool-Aid? Sounds harmless right?

Well the government has already created the Kool-Aid Committee It is called Mandatory Health Insurance. It requires every American to have health insurance “if they can afford it” or they will be provided a voucher if they cannot. It also requires employers with over 50 employees to offer insurance.

Officials have been gunning for the Healthcare industry for quite some time now. Thinking there is too much money in it and they want their piece of the pie. The Public spends money on premiums, copays, coinsurance, supplements, elective surgeries, medi-spas, and much more. And the government wants to share the wealth. Of course they would, they are stuck with dmv, trash, and water services. Healthcare must look like a gold mine. They started by cutting Medicare / Medicaid fees then tacked on some regulations, and fines and EMR and cut fees again. Then it was on to discuss pay for performance models and ACO’s.

Is requiring a citizen to carry health insurance constitutional?

Now this policy will change many times before it is implemented, in the end what do you think they will require physicians to do? Is requiring physician participation ethical? Constitutional?

The Obama administration made a major concession last week when it announced that it was scrapping the long term care program known as ‘Community Living Assistance Services and Supports’ (Class). Kathleen Sebelius, the secretary of Health and Human Services (HHS) said that she had concluded that premiums would be so high that few healthy people would sign up. The program, which was intended for people with chronic illnesses or severe disabilities, was championed by Senator Edward Kennedy before his death.

Kathy J. Greenlee, the assistant secretary of health and human services in charge of the program, said: “We do not have a viable path forward. We will not be working further to implement the Class Act.”

Two early critics of the Class program — Senator John Thune of South Dakota and Representative Charles Boustany Jr. of Louisiana, both Republicans — said they had been vindicated. “The Obama administration ignored repeated warnings about the financial solvency of this massive new entitlement and suppressed information on the viability of the program,” Mr. Thune said. In an interview, Mr. Boustany said that “in their haste to get the bill passed,” President Obama and Congressional Democrats ignored warnings about the program’s financial risks. When Congress was developing the program in late 2009, Senator Kent Conrad, Democrat of North Dakota and chairman of the Budget Committee, described it as “a Ponzi scheme of the first order” because it required an ever-increasing stream of premiums to cover the cost of benefits.

The implications of this decision by the Obama administration may be far reaching. The first item that comes to mind is: if the administration can arbitrarily decide not to pursue one provision of the Patient Protection and Affordable Care Act (PPACA), then how can we, as citizens of America trust them to enforce any aspects of the PPACA, passed by Congress in 2009. Additionally, the PPACA entails so many different provisions that require insurance companies or employers to provide certain benefits at no cost to policy holders that insurance premiums will necessarily have to rise, increasing the costs of health insurance for everyone. If the Federal Government can decide not to enforce one provision of the PPACA because of cost, then what is to prevent any insurance company from deciding not to include certain mandated coverage because of cost? What is the difference, other than the Government has the force on its side?

There are claims that the CLASS act within the PPACA was to account for 40% of the total savings that the PPACA was suppose to afford the country. Now that this aspect of the PPACA has been removed from the equation, the supposed savings for the Federal government has to be reevaluated and the Federal budget adjusted accordingly. If the additional funds now required to fund the entire PPACA are not available, then what is the ultimate fate of the PPACA? Is it even feasible to implement the law?

Politically, if the proponents of the PPACA decided to include the CLASS provision within the PPACA despite warnings from respected members of Congress, on both sides of the aisle, then what other unsustainable aspects are lurking within the PPACA. The first one that comes to mind is the reported double counting of the savings in Medicare/Medicaid programs, which allow the proponents of the PPACA to claim that the PPACA is revenue neutral or will even save the country Billions of dollars over a ten year period.

What does mean to the private practice healthcare provider? Initially, probably not much. Healthcare providers will still be required to implement Electronic Medical Records into their practices, and other mandates within the PPACA, until it is declared void or unconstitutional. There will probably be a greater urgency to reduce Medicare/Medicaid payments to healthcare providers to reduce the budgetary shortfall. There will probably be even greater incentives to pursue perceived Medicare/Medicaid fraud cases to reduce payment sto healthcare providers. However, the long term aspect of this situation is that the entire PPACA probably is not financially viable.

An interesting legal question that arises is the non-severability clause written into the PPACA. The proponents purposely wrote the non-severability clause into the bill because they knew that the entire bill’s financial viability was dependant on the healthcare insurance mandate, which is the clause being challenged by the states. If the government admits that one aspect of the program is unsustainable and not being enforced, then does that make the entire bill void, due to the non-severability clause?

The latest incarnation of managed care organizations are the Accountable Care Organizations (ACO) which are an important part of the Patient Protection and Affordable Care Act (PPACA). ACO’s promise to save the government billions of dollars in healthcare outlays by supposedly decreasing the amount of unnecessary medical care provided for the patient. The assumption is that there are billions of dollars of unnecessary medical treatment billed to the governmental payers- Medicare and Medicaid

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The first go round with managed care- the Preferred Provider Organizations PPO’s and Health Maintenance Organizations HMO’s of the 1980’s were a strictly financial decision. How much were the healthcare providers willing to discount their fees for an increased amount of patients? The doctor was able to make this decision based on the numbers. While it was frustrating to discount fees, at least the doctor could make the decision to discount their fees, and possibly increasing overall income, without compromising patient care.

ACO’s, the current concept of managed care organizations not only require doctors to reduce fees, but also intrude into the amount of healthcare that the patient receives. ACO’s often set the fee structure so low that it costs the doctor or hospital to perform the procedure. ACO’s may also completely disapprove or disallow certain diagnostic or therapeutic procedures that the doctor deems necessary for the patient. The contract with the ACO will usually contain language which prohibits the healthcare provider from billing the patient for any procedure that has been disallowed, or for any co-payment. So if you, as the doctor, determine that a certain procedure or treatment is necessary for the patient, you must provide the care free of charge.

The only reason for an ACO’s existence is to reduce the cost of medical treatment. The only way they can do this is to reduce medical treatment allowed to be provided to the patient. There is no consideration for the well being of the patient. I have never been asked by a managed care organization to take more x-rays, or provide more rehab for a patient. Has anyone out there ever had a request to do so?

The government tells the public that ACO’s will save healthcare dollars by decreasing fraud and waste within the system. The assumption that there are billions of dollars of waste or fraud in the system is incorrect, in my opinion. But be that as it may, by adding another layer of oversight, the ACO must cut even more in medical treatment costs to pay for this wasted layer of management. This is the government’s way of setting up the healthcare providers as the fall guys when healthcare is decreased under the PPACA.

The moral dilemma comes when you, as the provider, determine that your patient requires a procedure that is denied by the ACO. Do you provide the treatment, even if it costs you money to do so? Also at issue is the question: “At what point, and who becomes responsible for any malpractice liability that results from the procedure not being performed? My guess would be the treating healthcare provider, as I’m sure that the PPACA protects the ACO from any liability, though I have not the entire 1300 page law.

The only way to resist this intrusion into the doctor-patient relationship is to refuse to participate in the process. If the entire healthcare provider field refuses to enroll in the ACO’s or any other type of managed care organizations, such as Medical Homes, then the entire concept will be unworkable. Signing up for networks that cut fees and do not allow the doctor to provide necessary treatment for patients has a definition attached to it.

Remember the story by Winston Churchill about the man who asked a lady if she would sleep with him for a million pounds. She replied that she would. The man then asked her if she would sleep with him for 20 pounds. She was shocked, “What kind of woman do you think that I am?” she retorted. He replied, “We already determined that. Now we are just haggling over the price.”

If we allow any ACO to determine what type of care our patients require, or how much, we are no different than the woman in Churchill’s story.